RNTCP FIELD VISIT REPORT AT INTRODUCTION

Jiribam is a small, newly created district in with a population of about 45, 000. It is located at an isolated and difficult geographical terrains, located about 220 km away from the state capital of . The administrative and infrastructure are generally lacking. It borders with , and a number of labourers and refugees with poor nutrition seems to reside in the district. Health facilities are also generally lacking. The newly inaugurated hospital is yet to be fully functional due to lack of facilities and human resources. Since it is a newly created district, the District TB Centre (DTC) and Tuberculosis unit (TU) are not yet established. After creation of the new district, there is no new additional manpower/human resource except the newly designated District TB Officer (DTO). Since it is a potential district with high TB burden, a team comprising of the following RNTCP officials visited Jiri District from 29th to 31st January 2018 1. State TB Officer 2. Sr. Medical Officer 3. State PPM Coordinator 4. Sr. Laboratory Technician, IRL 5. Statistical Assistant, DR-TB Centre, JNIMS AIM: 1. Effective implementation of Schedule H1 of Drug & Cosmetic Rules with the aim to enhance TB notification through the pharmacies & to entrust the pharmacists to be the DOT providers/treatment supporters wherever appropriate. 2. Identification of space for a. District DR-TB Centre b. CBNAAT laboratory c. Drug store 3. Strengthening of RNTCP activities

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ACTIVITIES & OBSERVATIONS: - I. DESIGNATED MICROSCOPIC CENTRE/LABORATORY: Infrastructure of the laboratory is generally good. Only one STLS is posted, no lab tech is officially posted. There is no running water. The availability of lab reagents is being dependant on DTC, Imphal East which is nearly 220 km away from Jiribam with poor/irregular public transport system. Travelling to DTC- Imphal East is a very costly matter for the RNTCP staff as RNTCP is facing chronic fund constraint, providing irregular salaries resulting in poor program activities. There is no X-ray facility and CBNAAT. DTO is entrusted with additional charge of MO i/c of Jiribam Hospital, which is located about 7 km from the DMC. The DTC/DMC complex has enough space for establishing a drug store. RECOMMENDATIONS: - i. One lab technician should posted in the DMC. As the lab in the main hospital is not in working condition, one lab technician may be utilized from the hospital till a permanent one is posted. The CMO may be approached for the same. ii. The lab reagent should be procured & prepared in the DMC-Jiribam itself. The proposal for the required equipment & reagents may be put up to the STO. iii. A convenient space should be identified for a new drug store iv. All the diagnosed TB patients should undergo UDST (CBNAAT) under RNTCP IMPLEMENTATION OF SCHEDULE H1: II. A number of pharmacies in the new district were visited with a team comprising of STO, DTO (Jiribam), PPM Coordinator, STLS (Jiribam). One on one interaction with each pharmacists was done explaining about the Gazette notification on schedule H1 drugs with main emphasis on selling of anti-TB drugs, incentives about the TB notification to RNTCP, advantages of being DOT provider for the patients, nutritional supports to the patients, general awareness of tuberculosis with the emphasis to refer patients all presumptive TB in and around their locality. The danger of not reporting TB cases were also explained in details.

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Explanations on how to fill up the Schedule H1 registers and how & whom to report was done. A Whatsaap group was also created with all the pharmacists for easy communication was also made. It was observed that few pharmacies were already selling anti-TB drugs prescribed by the private practioners.

The team also looked for the private practitioners and private institutes in the area. Practically, there was only one private practioners who comes every Monday and Thursday from Silchar to practice in Jiribam. Unfortunately, by the time the team arrived on Monday he (the private practioners) had left. RECOMMENDATIONS: - i. DTO and his team should cover all the remaining pharmacies which were closed at the time of the visit by the team ii. All the patients already taking anti-TB drugs from pharmacies prescribed by private practioners should be registered and entered in Nikshay. iii. The DTO and his team should approach the lone private practioners and provide the basic information about RNTCP viz. (1) availability of free diagnostic facilities in RNTCP including CBNAAT, (2) free anti TB drugs available in RNTCP even for the private patients prescribed by the private practitioners, (3) opportunity to be a DOT provider/treatment supporter, (4) incentive of Rs. 1000/- for notifying TB by private practioners, (5) awareness about the nutritional support offered by RNTCP @ Rs. 500/- per TB patient per month till treatment is completed, (6) commitment of Indian Government to end TB by 2025, (7) important role of private practioners/ institutes in the National TB Control Program (8) Universal Drug sensitivity test (UDST) for all the TB patients diagnosed, & (9) danger of not notifying TB patients III. PROPOSAL FOR DISTRICT DR-TB CENTRE: - As the district is 220 km away from the state capital and being a very difficult geographical terrain, a district DR-TB Centre has been proposed. Adequate space is available in the new District Hospital which is not fully functional as yet. However a tentative space for male and female wards was identified in consultation with the Chief Medical Officer and the Medical Superintendent, Jiribam. Separate toilet for male & female is also available in the space identified.

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PROPOSAL FOR CBNAAT LABORATORY: - As for the same reason for the need of establishing a District DR-TB Centre, setting up of CBNAAT lab was felt, not because of appropriate population but considering the geographical location. All the diagnosed TB patients need to be subjected to UDST and patients cannot travel long distance for investigation because of weakness as well as due to individual economic condition. Sending samples in the long distance in cold box, limited time factor within which the sample has to reach the lab and also need a lot of coordination with the lab. Considering all the above factors, a room for establishing a CBNAAT lab was also identified in the same district Hospital.

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After the completion of field visit, the team along with the CMO and DTO went to meet the Deputy Commissioner, Jiribam at 2 pm on 30th January to appraise of the prevailing situation and for possible improvement of the program, however he was unavailable in his office Following that, the team had a meeting with the CMO discussing all the issues and he has assured all possible cooperation and help for the betterment of the program towards ending TB by 2025. The meeting and the visit concluded at 4 pm.

It was also decided that the DTO should provide the action taken report of the recommendations within 2 weeks and submit monthly progress report by 10th of every month.

Dr. Y. Gopalkrishna Singh State TB Officer Dated the 1st February 2018 Manipur Final budget sheet pip

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